Provider Demographics
NPI:1841555463
Name:EIRWIN-MAQUEDA, BRITTANY CAROL (DMD)
Entity type:Individual
Prefix:DR
First Name:BRITTANY
Middle Name:CAROL
Last Name:EIRWIN-MAQUEDA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 WEST STATE ROAD 66
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47635-9259
Mailing Address - Country:US
Mailing Address - Phone:812-649-4416
Mailing Address - Fax:
Practice Address - Street 1:3430 W STATE ROAD 66
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:IN
Practice Address - Zip Code:47635-9259
Practice Address - Country:US
Practice Address - Phone:812-649-4416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011855A1223G0001X
KY91891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201115460AMedicaid